Hypocrisy is such a ubiquitous feature of democratic politics that it can be hard to take it seriously. Indeed, taking it seriously is sometimes held to be a sign of political immaturity, or worse still, just more hypocrisy. We know that politicians can’t possibly sustain all the absurd contortions we demand of them as the price for securing our votes. In such circumstances, to insist that democratic politicians should honour all their promises, and practise what they preach, is itself absurd, and likely to breed cynicism and contempt. In an essay entitled ‘Hypocrisy and Democracy’ in his wonderfully measured new collection, Dennis Thompson quotes Judith Shklar, who described the politics of anti-hypocrisy as an ‘unending game of mutual unmasking’, in which everyone is bound to lose. Because democracy is a system of government that institutionalises distrust, as the price we pay for handing over so much power to our representatives, it is all the more important that we shouldn’t destroy what little trust remains, by imposing impossibly high standards. ‘We should learn to tolerate some inconsistency between the promises and performances of politicians,’ Thompson writes, ‘and perhaps even more between their private and public lives.’ If we don’t, politics will end up in the hands of the cynics and the prigs.

Thompson does not conclude, however, that we should therefore cease to worry about hypocrisy. He distinguishes between personal and what he calls ‘institutional’ hypocrisy, and suggests that in our preoccupation with the former we have forgotten that it is the latter which really matters. Institutional hypocrisy involves ‘a disparity between the publicly avowed purposes of an institution and its actual performance or function’. Thompson cites the example of the United States Constitution during the early part of its history, when the principles of liberty and equality that it proclaimed had to coexist with the practice of slavery that it also served to legitimise. This, he points out, is a far more significant feature of American politics than the parallel charge of individual hypocrisy routinely levelled against Thomas Jefferson and other champions of liberty, who happened to own slaves. Institutional hypocrisy can coincide with personal hypocrisy, but it doesn’t have to. It is also consistent with deep personal sincerity, and such sincerity will often be one of its causes. Oliver North, for instance, was not a hypocrite in any conventional sense, in that his behaviour was neither primarily self-serving nor inconsistent. It was North’s sincerity that enabled him to subvert the institutions for which he worked, and turn them against their own principles. ‘His main moral fault was not that he failed to be true to himself,’ Thompson writes, ‘but that he failed to be true to those to whom he was accountable. In his individual sincerity, he created and sustained an institutional hypocrisy.’

It is one of the striking features of the current political argument about the way healthcare in Britain should be funded that personal hypocrisy is not much of an issue. Tony Blair may not be able to bring himself to educate his children in the comprehensive system that has to suffice for most parents, but when it comes to health he is happy to take his chances with the NHS (knowing, of course, that he will be well looked after). Equally, Blair does not seem to have mixed motives when it comes to healthcare (in education a preference for selection is almost certainly concealed behind the rhetoric of universal provision). There is no reason to suppose that he doesn’t mean what he says when he talks about maintaining the NHS as a non-discriminatory system that is free at the point of delivery and treats all patients equally regardless of their ability to pay. This government genuinely wants to do its best for the NHS. Like Oliver North, the architects of New Labour’s health policy are nothing if not sincere.

The question, then, is one of institutional hypocrisy: can the NHS be true to itself if the government acts on a sincerely held belief that what it needs is an injection of private capital plus market-style competition to generate patient choice? Allyson Pollock thinks that the answer to this question is an unequivocal no. She argues that New Labour’s reforms of NHS funding, which build on but also threaten to go much further than the Tory reforms of the 1980s and 1990s, constitute a betrayal of the basic principles of a nationalised health service. The most fundamental of these principles is that healthcare should be provided on the basis of patient need, not on the basis of marketability, or cost-efficiency, or the appearance of choice. Her book is a furious denunciation of the institutional hypocrisy that results from seeing the failures of the NHS as competitive failures, rather than as consequences of the failure of successive governments to invest enough money in the service. Pollock believes that New Labour’s reforms will inevitably destroy the capacity of the NHS to meet the goal that it was ‘originally created to achieve’: a system of national healthcare that is publicly funded and, in consequence, fair.

Accusations of institutional hypocrisy can, however, be overplayed. The risk of insisting too strongly on the inviolability of a set of pre-existing commitments is that the charge of hypocrisy can give rise to its opposite, sanctimony. (One only has to think of the sanctimony of some of those who insist on the inviolability of the original purposes of the American Constitution.) Institutions must be allowed to adapt from their original purposes if the circumstances in which they operate have changed. Three things have happened which have altered the task faced by the NHS. First, demand for its services has hugely increased, in line with an ageing population and rising expectations about what healthcare should consist of. Second, the care it is able to offer has been greatly enhanced by progress in medical science. Third, the patients it treats have come to expect a certain level of personal service, as befits their experiences as consumers in other contexts. Taken together, these pressures have made it increasingly difficult to conceive of the NHS as a needs-based institution. It is no longer clear what patients need, or how many of these needs can be met, or whether their needs can be clearly distinguished from what most patients have simply come to want. As a result, the NHS has been forced to change. Needs have given way to rights, and what we have now is what a recent King’s Fund audit of the state of the NHS called ‘a set of rights to treatment, at specified and assured standards, from a widening base of diverse suppliers, public and private’.

The full text of this book review is only available to subscribers of the London Review of Books.

Letters

I had not long finished reading David Runciman’s cautionary article on the commercialisation of the NHS (LRB, 21 April) when I happened on a few lines in the newspaper to the effect that a man of ninety who was a patient in a hospital somewhere in the North of England had been left lying on a mattress on the floor because the lease had run out on his bed. This seemed to be taking commercialism rather beyond any acceptable limit, even for those of us who are not fanatically opposed to the Private Finance Initiative as a way of raising ready money to pay for new hospital buildings. If local hospital trusts find it good practice to rent beds from outside rather than buy and own them, it can only be because it works out cheaper in the long run, the long run being the prime consideration if laying out more money in the short term involves you in having to raise it from somewhere or somebody who is unwilling to pay up. The only reason we have the PFI in the first place, as Runciman indicates, is that we are presumed by New Labour to be so unwilling to pay more taxes to fund new hospital building from public sources that we might decide to vote for the other lot when the day comes, as it’s just about to. It may of course be the case that the story about the floored nonagenarian up north isn’t true, but was offered to the press as one of those ‘hateful’ – Runciman’s word, and how right he is – individual cases of which so much is made at election time. The fact that the Tory Party seems not to have picked up on it makes me wonder whether even they were suspicious of its authenticity. They have instead, at least where I live, put out an election poster claiming that since New Labour took charge of the NHS, we’ve had three times as many MRSA bugs in our hospitals as when the Conservatives had charge of them – these nasty little foreign bacteria are presumably the medical equivalent of illegal immigrants. The long-term answer to the problems of the NHS may in any case not lie with governments of either colour. If commercialisation is held to be the solution why not hand it over to what is patently the most successful commercial organisation currently in our midst? ‘This does not mean that schools and hospitals should try to be more like supermarkets,’ Runciman writes. But why not? Given that Tesco appears to be able to make £2 billion honest profit in a single trading year, it’s surely time they were invited to start building a Tesco wing for the local hospital rather than opening yet more of their awful convenience stores.

Hilary Fanning
Horsham, West Sussex

David Runciman’s account of the injection of choice into the NHS doesn’t mention ‘Choose and Book’, a project intended to transform the process of allocating outpatient appointments. Instead of being put on a waiting list and subsequently given a date for an appointment, patients will be able to book appointments with the help of their GP, through a call centre or via the web. Not only will they be able to pick a date that suits them, they will be offered a choice of hospitals, including private ones. The project made the headlines when the National Audit Office reported that although it had been hoped that 205,000 patients would have taken advantage of the new system by December 2004, only 63 patients had used it.

Some of the rhetoric that surrounds this initiative is illustrative of the institutional hypocrisy Runciman describes. The Choose and Book website boasts that you will get your appointment faster. But getting your appointment faster doesn’t mean that you will be seen sooner. Under the present system a patient seeing their GP in, say, April might be told in June that their appointment will be in July. With Choose and Book the patient will be told the appointment date in April, but it’s actually less likely to be as soon as July. The project is mentioned in a section of the Labour Party manifesto called ‘Choosing Not Waiting’, but as a result of the constraints involved in offering choice and guaranteeing availability patients will in fact have to wait even longer to be seen.

Paul Taylor
University College London

It is true that the subsidy system which has been used to allow the construction of foundation hospitals leaves much to be desired, but the principle that patients, former patients and staff should elect the boards of governors of foundation hospitals is an excellent one and should be extended to all NHS hospitals. David Runciman is wrong to allege that these boards of governors have no power. They are able to appoint or remove non-executive directors, and to decide their pay, allowances and other terms and conditions.

David Runciman hasn’t got the economics of PFI quite right (LRB, 21 April). More than once he says that Labour has looked to the private sector for additional capital. That argument was widely used by New Labour ministers in the mid-1990s to bring around laggards in the constituencies. The trouble is, it isn’t true (and that’s why you never hear them say it any more). Under PFI, the private sector finances capital expenditure, i.e. borrows the money for it, while the public sector funds it through the annual payments it makes to PFI consortia. Any additional capital is thus paid for by the public sector alone. PFI is a mechanism by which the government borrows through an intermediary (at a higher rate of interest than if it had borrowed in its own name). Allyson Pollock shows in NHS Plc how the high costs of PFI-related debt servicing have led to major reductions in NHS capacity: since 1997, 12,000 NHS beds in England have closed (5 per cent of the UK total), many of them in hospitals procured under the PFI. The first 14 PFI hospitals had their budgets cut by 25 per cent, which they mostly managed by hiring fewer nurses. All Labour’s arguments in favour of PFI now turn on risk transfer, which Runciman rightly takes a jaundiced view of as there is little evidence of the private sector assuming any real risk. The PFI debt bubble and associated contractual problems are already unravelling: witness the Jarvis schools PFI scheme in Brighton.

Pace Runciman, there is every reason to suppose that Blair does not mean what he says when he talks about maintaining the NHS as a non-discriminatory system that is free at the point of delivery. As Pollock points out, he is the first prime minister to introduce time limits on NHS care, and to introduce charges for personal and nursing care in NHS hospitals.

Neil Vickers
King’s College, London

I note from David Runciman’s article that the health secretary no longer answers questions about the operations of foundation hospitals in view of their relative independence. Do we know how much John Reid’s salary has been reduced to reflect his reduced responsibilities?